Journal of Clinical and Translational Research 2016; 2(3): 84-90

Journal of Clinical and Translational Research

Journal homepage: http://www.jctres.com/en/home

REVIEW

The role of TNF-α in rheumatoid arthritis: a focus on regulatory T cells

Mark Farrugia, Byron Baron*
Center for Molecular Medicine and Biobanking, Faculty of Medicine and Surgery, University of Malta, Msida, Malta

A RT I C L E I N F O ABSTRACT

Article history:
The autoimmune disorder rheumatoid arthritis (RA) causes chronic inflammation and destruction of joints.
Received: June 4, 2016
Revised: September 7, 2016 T cells are a predominant component of the synovial environment in RA, however the functional role of
Accepted: September 12, 2016 these cells is not yet fully understood. This is in part due to the fact that the balance and importance of the
Published online: September 15, 2016 relation of Tregs with T-effector cells in RA is still under investigation.The current treatment regimen for this
debilitating disease focuses on controlling symptoms and preventing further joint damage through the use
Keywords: of therapies which affect different areas of the immune system at the synovium. One of the main therapies
rheumatoid arthritis involves Tumor Necrosis Factor alpha (TNF-α) inhibitors. In the RA immune-environment, TNF-α has been
regulatory T cells shown to have an influential and extensive but as yet poorly understood effect on Treg function in vivo, and
TNF-α therapy undoubtably an important role in the treatment of RA. Interestingly, the high levels of TNF-α found in RA
joint inflammation patients appear to interfere with the mechanisms controlling the suppressive function of Tregs.
Relevance for patients: This review focuses on the conflicting literature available regarding the role
played by Tregs in RA and the impact of TNF-α and anti-TNF-α therapies on Tregs in this scenario. Individu-
als suffering from RA can benefit from better insight of the treatment mechanisms of the immunologic
processes which occur throughout this disease, as current treatments for RA focus on several different areas
of the immune system at the synovial compartment.

(FLS) adhesion and invasion. These processes lead to the

1. Introduction
Rheumatoid arthritis (RA) is an autoimmune disorder that
manifests itself as a chronic inflammation of the lining of the
joints, with significant morbidity and mortality rates if left
untreated [1]. RA is characterized by synovial inflammation
and hyperplasia (swelling), autoantibody production (rheuma-
toid factor (RF) and anti-citrullinated protein antibody (AC-
PA)), cartilage and bone destruction, and systemic features,
including cardiovascular, pulmonary, psychological, and
skeletal disorders [2]. Possible risk factors for the development
of RA include genetic background, smoking, silica inhalation
and periodontal disease [1].
A hyperplastic synovium is the major contributor to the car-
tilage damage in RA. The loss of the protective effects of the
synovium result in the alteration of the protein-binding char-
acteristics of the cartilage surface, promoting synoviocytes
destruction of the surface [2]. Bone erosion then follows rap-
idly (affecting 80% of patients within 1 year after diagnosis
[1]). Cytokines present in the synovial fluid, particularly
macrophage colony-stimulating factor (M-CSF) and receptor
activator of NF-κB ligand (RANKL), promote osteoclast dif-
ferentiation and invasion of the periosteal surface adjacent to
articular cartilage [3]. Tumor Necrosis Factor alpha (TNF-α)
and Interleukin (IL) -1, 6, and potentially 17 amplify osteoclast
differentiation and activation.
Studies in Europe have shown that there is a gradient in the
prevalence of RA, starting from a low prevalence in the South
(e.g. Italy 0.31%) [4], to a higher prevalence in the North (e.g.
Finland 0.8%) [5]. While no formal epidemiological studies on
RA have been carried out in Malta yet, a total of approxi-
mately 600 patients with the disease are followed up at the
Rheumatology Clinic at St. Luke's Hospital, giving a preva-

*Corresponding author:
Byron Baron
Center for Molecular Medicine and Biobanking, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
E-mail: byron.baron@um.edu.mt

Distributed under creative commons license 4.0 DOI: http://dx.doi.org/10.18053/jctres.02.201603.005

 Farrugia and Baron | Journal of Clinical and Translational Research 2016; 2(3): 84-90
lence of 0.16% [6].
The use of different case definitions makes the estimates
vary as widely as 25 to 115 per 100,000 [7]. The annual inci-
dence rate of RA recorded in studies varies between 20 and 50
cases per 100,000 in Northern European countries, but there
are indications that it may be lower in Southern European
countries [8,9]. Studies of the incidence and prevalence of RA
suggest variations between different populations even within
the same country. Possible explanations include regional varia-
tion in behavioral factors, climate, environmental exposures,
RA diagnosis, and genetic factors [7].
Currently, treatment focuses on controlling symptoms and
preventing further joint damage. Medications used in the
treatment of RA include non-steroidal anti-inflammatory drug
(NSAIDs), disease-modifying anti-rheumatic drug (DMARDs),
TNF-α inhibitors, IL-6 inhibitors, T-cell activation inhibitors,
B-cell depletors, Janus kinase (JAK) inhibitors, and steroids
[10] (Figure 1). Since all current treatments for RA are focus-
ing on different areas of the immune system at the synovial
compartment, a good understanding of the immunologic
processes which occur throughout RA is vital for a better in-
sight of the treatment mechanisms themselves.
Figure 1. Summary of therapies for rheumatoid arthritis. Treatment
regimens for RA have been generally divided into two. The first category
contains the non-steroidal anti-inflammatory drugs (NSAIDs) and
glucocorticoids, which block effector T-cell activation and reduce in-
flammation. Other therapies such as immunosuppressants, steroids and
biological therapies are grouped under the non-specific term of
disease-modifying anti-rheumatic drugs (DMARDs) and these include:
Tumor Necrosis Factor alpha (TNF-α) inhibitors (which diretly block
TNF-α), Interleukin (IL-1 and IL-6) inhibitors (which target cartilage
destruction via synovial fibroblast modulation), immune-suppressants
(which inhibit surface adhesion molecules), T-cell activation inhibitors
(that bind to differentiated T cells, reducing overall T-cell numbers),
B-cell depletors (which act specifically by targetting and destroying
B-cells) amd Janus kinase (JAK) inhibitors (blocking signal transduction
of cytokine receptors).
Distributed under creative commons license 4.0
85
2. Synovial immunological processes
Several of the risk alleles linked to RA consistently map
functionally with immune regulation such as the nuclear factor
kappa-light-chain-enhancer of activated B-cells (NF-κB)-de-
pendent signaling, T-cell stimulation, activation, and functional
differentiation. This suggests that these immunologic pathways
are amongst the key modulators of the development of the
autoimmune inflammation in RA [11-13].
The costimulation-dependent interactions among dendritic
cells, T cells, and B-cells are thought to occur primarily in the
lymph node, generating an autoimmune response to citrulline-
containing self-proteins [2]. The inflammation of the synovial
membrane (synovitis) is then caused by the infiltration of leu-
kocytes in the synovial compartment. Leukocyte migration is
enabled through various pathways, mainly through the activa-
tion of endothelial tissue in synovial micro-vessels, resulting in
an increase in expression of adhesion molecules and chemo-
kines [14]. This and other processes result in the build-up of
inflammatory synovial tissue (Figure 2).
Figure 2. The role of TNF-α in rheumatoid arthritis. Immune regulation is
at the heart of RA with the generating of an autoimmune response, with
TNF-α being a major player. Dendritic cells, T cells, and B-cells are
costimulated, and this leads to T-cell activation and functional differentia-
tion. The stimulated macrophages in turn activate nuclear factor kap-
pa-light-chain-enhancer of activated B-cells (NF-κB)-dependent signaling,
which induces pro-inflammatory cytokines that enhance local inflamma-
tion of the synovial membrane (synovitis) and result in damage to
cartilage and bones.
A variety of innate effector cells, including macrophages,
mast cells, and natural killer cells, are found in the synovial
membrane, while neutrophils reside mainly in synovial fluid.
The main role of macrophages in this scenario is that of
releasing cytokines (e.g., TNF-α and interleukin-1, 6, 12, 15,
18, and 23), reactive oxygen intermediates, nitrogen interm-
ediates, production of prostanoids and matrix-degrading
enzymes, phagocytosis, and antigen presentation [15].
Neutrophils on the other hand contribute to synovitis by
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 86 Farrugia and Baron | Journal of Clinical and Translational Research 2016; 2(3):84-90
synthesising prostglandins, proteases, and reactive oxygen
intermediates [16]. These findings provide evidence that acti-
ation of the innate immune pathway contributes to synovitis.
It has become more apparent from various reports in the
literature that cytokines play an integral role in the activation
and maintanence of the innate immune pathway. Cytokine
production that arises from numerous synovial cell populations
is central to the pathogenesis of RA [13]. TNF-α is one such
cytokine and plays a fundamental role through the activation
of cytokine and chemokine expression, expression of endot-
helial-cell adhesion molecules, protection of synovial fibro-
blasts, promotion of angiogenesis, suppression of regulatory T
cells, and induction of pain [17,18]. The central role of this
cytokine has been repeatedly confirmed by a successful
therapeutic blockade of membrane and soluble TNF-α in
patients with RA.
3. TNF-α
TNF-α is an inflammatory cytokine consisting of a trimeric
protein encoded within the major histocompatibility complex.
It’s first identified form was the 17 kDa secreted form, but
further research then showed that a noncleaved 27 kDa
precursor form was also present in transmembrane form [19].
TNF-α and its specific receptors TNFR1/TNFR2 are the major
members of a gene superfamily of ligand and receptors which
are respondible in regulating essential biologic functions. The
extracellular domains of TNFR1 and TNFR2 are homologous
and have similar affinity for TNF-α, however the cytoplasmic
regions of these two receptors are distinct and mediate
different downstream events. TNFR1 signalling is the major
mechanistic pathway responsible for the effects of TNF-α [20].
These receptors are expressed on all somatic cells.
4. Role of T cells in rheumatoid arthritis
Even though T cells are a predominant component of the
synovial environment in RA, the functional role of T cells is
not yet fully understood. This is mainly due to the fact that
lymphocytes, including T cells, act and react according to the
presence and numbers of other subsets of lymphocytes, and
this systematic approach to immunity has only recently started
to be investigated in detail [21]. Therefore, it is vital to under-
stand all of the main protagonists in the synovium in our as-
sessment of the immunological processes taking place.
Activated CD4+ T cells stimulate monocytes, macrophages,
and synovial fibroblasts to produce the cytokines IL-1, IL-6,
and TNF-α [22]. Activated CD4+ T cells also stimulate B-cells
and these produce immunoglobulins, including the RF. The
precise immunologic role of RF is still unknown, but it may
involve the activation of complement through the formation of
immune complexes [23]. Activated CD4+ T cells also express
RANKL, and as explained previously, this stimulates osteo-
clast differentiation. Thus these activated T cells give rise to
cartilage erosion caused by excessive osteoclasts [24].
RA is conventionally considered to be a disease mediated
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by type 1 helper T cells, however there is increased attention
on the role of type 17 helper T cells (Th17). Th17 is a subset of
T cells that produces interleukin-17A, 17F, 21, and 22 and
TNF-α [25,26]. Other cytokines which support the differentia-
tion of Th17 cells are macrophage-derived and dendritic
cell–derived transforming growth factor β (TGF-β) and IL-1, 6,
21, and 23 [26].
It is interesting to note that IL-6 suppresses the differentia-
tion of regulatory T cells (Tregs), thus shifting T-cell homeosta-
sis toward inflammation rather than autoregulation [27]. It is
now well accepted that Tregs are critically involved in immune
tolerance and homeostasis. Tregs that are detected in tissues
from patients with RA seem to have limited functional capa-
bility, as inferred via Forkhead box P3 (FoxP3) transcript
levels, which are lower in the synovial membrane compared to
those in peripheral blood or synovial fluid [28].
In RA, there are two distinct classes of Tregs depending on
their location: those found in the peripheral blood and those at
the site of inflammation, usually studied in the synovial fluid
(SF) [29-31]. Different studies report different accumulation
numbers of Tregs in the peripheral blood between healthy indi-
viduals and RA patients, varying from reports of decrease to an
increase in Tregs, comparatively [32-36]. In many scenarios
however, the lack of function of the Tregs themselves seems to
be observed. FoxP3+ Tregs sampled from the SF of RA patients
are able to suppress the proliferation of effector T cells [31],
but Ehrenstein et al. reported that, while Tregs from RA patients
do suppress proliferation, they are defective in their ability to
suppress pro-inflammatory cytokine production [34], and thus
this process is not regulated, resulting in inflammation. It is
important to note that this study was done with Tregs obtained
from peripheral blood rather than SF. On the other hand, a con-
flicting recent study also performed using Tregs obtained from
peripheral blood, shows that there is no significant difference
between the suppressive effects of FoxP3+ Tregs on certain cy-
tokines and the proliferation of effector T cells, between Tregs
obtained from healthy individuals and from RA patients [37].
Various studies provide compelling evidence that CD4+
FoxP3+ Tregs cells play an indispensable role in maintaining
immune homeostasis and in suppressing deleterious excessive
immune responses [38]. There are various subsets of Tregs, with
various effects on effector T cells in the autoimmune scenario [39].
Any disregulation or loss of function in Tregs will result in an
upregulation of T-effector cells and any other cell type under
suppression by Tregs. Thus it is important to understand better
how TNF-α, being one of the most present and influential
cytokines in the synovial immuno-environment, affects the
function of Tregs.
5. Effect of TNF-α on regulatory T-cell function in
rheumatoid arthritis
TNF-α and IL-7 are two cytokines which act against the
suppressive activity of human Tregs [40]. High levels of TNF-α
are found in both the serum and synovial fluid of RA patients,
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 Farrugia and Baron | Journal of Clinical and Translational Research 2016; 2(3): 84-90
and therefore this might be one of the factors which result in
defective Tregs function [41]. Treatment of these patients with
infliximab, an anti-TNF-α therapy, gave rise to an adaptive
FoxP3+ CD62L− Tregs population, which was able to suppress
cytokine production of effector T cells via a TGF-β and IL-10
pathway [42]. The fact that the naturally-occurring CD62L+
Tregs remained defective in infliximab-treated patients clearly
showed that TNF-α was responsible in promoting the devel-
opment of a new dysfunctional subset of FoxP3+ Tregs. Another
study highlighting the importance of TNF-α in RA vis-à-vis
FoxP3+ Tregs reported that overexpression of TNF-α in human
TNF-α transgenic mice led to the development of arthritis,
with an increased number of Tregs expressing the TNF receptor
II (TNFRII) [43]. TNFRII is a required receptor for TNF-α
interactions [44]. The TNF-α overexpression did not inhibit the
suppressive activity of the Tregs, however the Tregs still failed to
control inflammation. When TNF-α was blocked, a further
increase in the frequency of Tregs was observed, and these Tregs
had upregulated CTLA-4 expression, resulting in enhanced
suppressor activity [43]. The TNF-α also induced the differen-
tiation of a CD62L- Treg population as observed in the previ-
ous study [42].
These studies suggest that TNF-α plays an important role in
the inhibition of FoxP3+ Treg suppressive function, particularly
in suppressing inflammation. Further to this, it has been shown
that TNF-α signaling via TNFRII downregulates FoxP3 ex-
pression in humans in both naturally-occurring Tregs and adap-
tive Tregs, and this results in the inhibition of Treg suppressive
activity [45]. Another study done using human cell cultures
showed that during the inhibition of active Tregs via TNF-α
signaling of the TNFRII receptor, the TNF-α activated the ca-
nonical NF- κB pathway and induced a pro-inflammatory
phenotype [46], however in this case FoxP3 expression was
not affected. The inhibition of Treg suppressive activity could
be reversed by treatment with anti-TNFRII antibody. This
shows that TNF-α signaling via TNFRII may be one mecha-
nism which leads to Treg defects in RA. This study was per-
formed using both Tregs from peripheral blood and synovial
fluid and the results showed similar trends in both types of
Tregs.
Another way TNF-α might inhibit Treg suppressive activity
is by influencing the formation of the immunological synapse
between Tregs and antigen presenting cells (APCs) [47]. Alt-
hough for effector T cells, protein kinase C-θ (PKC-θ) re-
cruitment to the immunological synapse is necessary for full
T-cell activation, for FoxP3+ Tregs, PKC-θ is concealed from
the immunological synapse. A study was conducted in which a
model system on supported planar bilayers containing the mo-
bile fluorescently labelled intercellular adhesion molecule–1
(ICAM-1), anti-CD3 antibodies and CD4+CD25+ effector T
cells or CD4+CD25+ Tregs (freshly isolated from peripheral
blood) was devised, in order to emulate the immunological
synapse. Addition of TNF-α to this model increased the PKC-θ
recruitment to the Treg immunological synapse, and this inhib-
ited their suppressive activity. This contrasts with the fact that
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87
after blocking PKC-θ, Treg function was enhanced [47]. This
study showed that inhibition of PKC-θ might protect Tregs from
inactivation by TNF-α and this restores the suppressive func-
tion of defective Tregs in RA patients. Disc large homolog 1
(Dlgh1) is another identified molecule involved in the immu-
nological synapse formation which regulates Treg function in-
dependently of PKC-θ [48]. Dlgh1 was found to be recruited
to the immunological synapse four times as much in Tregs than
in effector T cells. It was also found that Tregs from RA patients
with active disease had defective Dlgh1 recruitment to the
immunological synapse. This defective recruitment resulted in
reduced suppressive activity of Tregs. Exposing healthy control
Tregs to TNF-α decreased the Dlgh1 recruitment and thus also
reduced Treg suppressive activity [48]. These findings suggest
that in FoxP3+ Tregs, PKC-θ-mediated negative and
Dlgh1-mediated positive pathways seem to regulate suppres-
sive function independently, and in RA, one or both of these
pathways may be defective as a possible con4equence of
TNF-α [49].
TNF-α was also found to interact directly with the
DNA-binding activity of the FOXP3 gene in Tregs [50]. In this
analysis done on human cells obtained from both the peripher-
al blood and the synovial fluid of RA patients it was shown
that TNF-α - TNF receptor-binding induces increased expres-
sion of protein phosphatase 1 (PP1). PP1 dephosphorylates
Ser418 in the DNA-binding domain of the FoxP3 transcription
factor, and this in turn reduces its DNA-binding activity, thus
impairing the suppressive function of Tregs.
Interestingly, although TNF-α is a major pro-inflammatory
cytokine, there is increasing evidence that indicates TNF-α
also has immunosuppressive feedback effects, as was demon-
strated in a study where both resting and activated mouse pe-
ripheral FoxP3+ Tregs purified from lymph node expressed re-
markably higher surface levels of TNFRII than effector T cells
in vitro [51]. In the same study it was observed that in co-cult-
ures of Tregs and effector T cells, suppression of effector T-cell
proliferation by Tregs was initially observed after exposure to
TNF-α, however longer exposure to TNF-α restored the sup-
pressive effects. Furthermore, TNF-α expanded Treg popula-
tions in this study, and these TNF-α-expanded Tregs had up-reg-
ulated expression of CD25 and FoxP3, enhancing the suppres-
sive activity of these Tregs. Thus in this study the stimulatory
effect of TNF-α on Tregs resembled the reported costimulatory
effects of TNF-α on effector T cells. Another study to deter-
mine the effect of TNF-α on Tregs showed that when Treg cells
were cultured for 20 h with or without IL-2 before the sup-
pression assays, the presence of TNF in the pre-culture had no
effect on their suppressive function in any assay condition [52].
This work also showed that in the presence of IL-2, the effects
of TNF on human Tregs in a 3-day culture of whole CD4+ T
cells resulted in an increased proportion of Tregs and the upreg-
ulation of FOXP3 expression. A suggestion for the slower re-
sponse of Tregs to TNF-α could be a delayed immunosuppres-
sive feedback effect [51]. Another study concludes that human
Tregs obtained from the buffy coat of healthy donors which
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 88 Farrugia and Baron | Journal of Clinical and Translational Research 2016; 2(3):84-90
were deficient in TNFRII were not able to control inflamma-
tory responses in vivo [53]. TNFRII expression on human Tregs
present in the synovial fluid of RA patients is also up-regulated
[45], presumably reflecting their enhanced suppressive capaci-
ty [33]. It is not clear whether TNFRII+ FoxP3+ Tregs are more
functionally suppressive (Figure 3).
Figure 3. The biochemistry of rheumatoid arthritis focusing on Tregs. In
RA patients high levels of TNF-α counteract the suppressive activity of
human Tregs, acting as a factor towards defective Treg function. One
mechanism is through increased protein phosphatase 1 (PP1) expression,
which physically interacts with the DNA-binding domain of the FoxP3
transcription factor and dephosphorylates Ser418, leading to decreased
DNA-binding activity. A second mechanism is through increased protein
kinase C-θ (PKC-θ) recruitment to the Treg immunological synapse. Yet
another mechanism is via reduced recruitment of disc large homolog 1
(Dlgh1) to the immunological synapse. Either or all of these can act in RA
patients to reduce Treg suppressive function.
Diverse roles of TNF-α in the immune response may be
partly explained by the existence of two forms of this cytokine:
a membrane-bound TNF-α (mTNF-α), and TNF-α which is
cleaved from the membrane and released as a soluble cytokine
(sTNF-α) [54]. Moreover, TNFRI and TNFRII have different
expression patterns and affinities for mTNF-α or sTNF-α, and
may transduce signals with opposite outcomes. TNFRII binds
with higher affinity to mTNF-α than to sTNF-α [55].
6. anti-TNF-α therapy effects and future work
It is clear from the conflicting literature above, that we are
still far from deducing the exact role and effect of TNF-α on
Tregs in the RA scenario. TNF-α seems to interfere with the
Distributed under creative commons license 4.0
mechanisms controlling Treg suppressive function, and there-
fore it is plausible to predict that anti-TNF-α therapies would
counter this effect. In fact, studies show that anti-TNF-α the-
rapy has a regulatory effect on the immune system of RA pa-
tients by promoting an increase in the proportion of Tregs and
suppressing effector T cells [56]. One such recent study
showed that the anti-TNF antibody adalimumab promoted the
interaction between monocytes and Tregs from RA patients by
binding to monocyte membrane bound TNF, enhancing its
expression and its binding to TNF-RII expressed on Tregs [57].
This resulted in adalimumab-expanded functional FoxP3+ Tregs
able to suppress Th17 cells through an IL-2/STAT5-dependent
mechanism. This study demonstrated that a therapeutic anti-
body thought to act by blocking TNF-α can also enhance the
regulatory properties of this pro-inflammatory cytokine.
However, clinical trials have accumulated evidence that an-
ti-TNF-α therapies might promote rather than suppress certain
forms of autoimmunity. In RA, anti-TNF-α therapy is some-
times associated with adverse events, such as multiple sclero-
sis and lupus [58]. Cases of juvenile arthritis patients who de-
veloped type 1 diabetes have been reported during therapy
with a TNF-α antagonist [59,60].
TNF-α without a doubt has an important role in the treat-
ment of RA, and it has been shown to have a powerful, varied
and yet poorly understood effect on Treg function in vivo in the
RA immune-environment. Although anti-TNF-α therapies have
been widely used to treat RA with significant clinical result,
more research is still needed to understand better the total ef-
fect of such therapies on all cell types involved in the synovial
immune-environment. Anti-TNF-α therapies might exhibit
serious side effects, and the mechanisms leading to such side
effects can be investigated further to find methods of sup-
pressing them. Alternate routes to suppress the over-reactive
effector T cells as well as activate and enhance the Treg subsets
can be investigated, whilst working to obtain a broader and
clearer picture of the effect TNF-α has on Tregs and RA in general.
Disclosure
The authors declare no conflict of interest.
References
[1] Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT,
Bingham III CO, Birnbaum NS, Burmester GR, Bykerk VP,
Cohen MC, Combe B, Costenbader KH, Dougados M, Emery
P, Ferraccioli G, Hazes JMW, Hobbs K, Huizinga TWJ,
Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard
HA, Moreland LW, Naden RL, Pincus T, Smolen JS,
Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS,
Vencovský J, Wolfe F, Hawker G. Rheumatoid arthritis class-
ification criteria: An American College of Rheumatology/
European League Against Rheumatism collaborative initiative.
Arthritis Rheum 2010; 62: 2569-2581.
[2] McInnes IB, Schett G. The Pathogenesis of Rheumatoid Ar-
thritis. N Engl J Med 2011; 365: 2205-2219.
DOI: http://dx.doi.org/10.18053/jctres.02.201603.005
 Farrugia and Baron | Journal of Clinical and Translational Research 2016; 2(3): 84-90
[3] Gravallese EM, Harada Y, Wang JT, Gorn AH, Thornhill TS,
Goldring SR. Identification of cell types responsible for bone
resorption in rheumatoid arthritis and juvenile rheumatoid ar-
thritis. Am J Pathol 1998; 152: 943-951.
[4] Cimmino MA, Zampogna A, Murroni S, Baruffi S, Alessio G,
Maio T, Mela GS. Methodology of an epidemiologic preva-
lence study in rheumatology: the Chiavari study. Reumatismo
2002; 54: 40-47.
[5] Aho K, Kaipaiainen-Seppanen O, Helovaara M, Klaukka T.
Epidemiology of rheumatoid arthritis in Finland. Semin Ar-
thritis Rheum 1998; 27: 325-334.
[6] Mallia C. Treating Rheumatoid Arthritis Yesterday and Today.
MMJ 2004; 16: 18-21.
[7] Carmona L, Cross M, Williams B, Lassere M, March L.
Rheumatoid arthritis. Best Practice Res Clin Rheumatol 2010;
24: 733-745.
[8] Carbonell J, Cobo T, Balsa A, Descalzo MA, Carmona L. The
incidence of rheumatoid arthritis in Spain: results from a na-
tionwide primary care registry. Rheumatology 2008; 47:
1088-1092.
[9] Pedersen JK, Kjaer NK, Svendsen AJ, Horslev-Petersen K. In-
cidence of rheumatoid arthritis from 1995 to 2001: impact of
ascertainment from multiple sources. Rheumatol Int 2009; 29:
411-415.
[10] Kumar P and Banik S. Pharmacotherapy Options in Rheuma-
toid Arthritis. Clin Med Insights Arthritis Musculoskelet Dis-
ord 2013; 6: 35-43.
[11] Begovich AB, Carlton VE, Honigberg LA, Schrodi SJ, Chok-
kalingam AP, Alexander HC, Ardlie KG, Huang Q, Smith AM,
Spoerke JM, Conn MT. A missense single-nucleotide poly-
morphism in a gene encoding a protein tyrosine phosphatase
(PTPN22) is associated with rheumatoid arthritis. Am J Hum
Genet 2004; 75:330-337.
[12] Plenge RM, Cotsapas C, Davies L, Price AL, De Bakker PI,
Maller J, Pe'er I, Burtt NP, Blumenstiel B, DeFelice M, Parkin
M. Two independent alleles at 6q23 associated with risk of
rheumatoid arthritis. Nat Genet 2007; 39: 1477-1482.
[13] Remmers EF, Plenge RM, Lee AT, Graham RR, Hom G, Beh-
rens TW, De Bakker PI, Le JM, Lee HS, Batliwalla F, Li W.
STAT4 and the risk of rheumatoid arthritis and systemic lupus
erythematosus. N Engl J Med 2007; 357: 977-986.
[14] Szekanecz Z, Pakozdi A, Szentpetery A, Besenyei T, Koch AE.
Chemokines and angiogenesis in rheumatoid arthritis. Front
Biosci (Elite Ed) 2009; 1: 44-51.
[15] Liew FY, McInnes IB. The role of innate mediators in inflam-
matory response. Mol Immunol 2002; 38: 887-890.
[16] Cascão R, Rosário HS, Souto-Carneiro MM, Fonseca JE.
Neutrophils in rheumatoid arthritis: more than simple final ef-
fectors. Autoimmun Rev 2010; 9: 531-535.
[17] Feldmann M, Brennan FM, Maini RN. Rheumatoid arthritis.
Cell 1996; 85: 307-310.
[18] Hess A, Axmann R, Rech J, Finzel S, Heindl C, Kreitz S, Ser-
geeva M, Saake M, Garcia M, Kollias G, Straub RH. Blockade
of TNF-α rapidly inhibits pain responses in the central nervous
system. Proc Natl Acad Sci USA 2011; 108: 3731-3736.
[19] Perez C, Albert I, DeFay K, Zachariades N, Gooding L, Mi-
chael K. A non secretable cell surface mutant of tumor necro-
Distributed under creative commons license 4.0
89
sis factor (TNF) kills by cell-to cell contact. Cell 1990; 63:
251-258.
[20] Amiot F, Fitting C, Tracey KJ, Cavaillon JM, Dautry F. Lipo-
polysaccharide-induced cytokine cascade and lethality in LT
alpha/TNF alpha-deficient mice. Mol Med 1997; 3: 864-875.
[21] Firestein GS. Evolving concepts of rheumatoid arthritis. Na-
ture 2003; 423: 356-361.
[22] Isler P, Vey E, Zhang JH, Dayer JM. Cell surface glycopro-
teins expressed on activated human T cells induce production
of interleukin-1 beta by monocytic cells: a possible role of
CD69. Eur Cytokine Netw 1993; 4: 15-23.
[23] Burbano C, Rojas M, Vásquez G, Castaño D (2015). Micro-
particles That Form Immune Complexes as Modulatory
Structures in Autoimmune Responses. Mediators Inflamm
2015; Article ID 26759.
[24] Kong YY, Feige U, Sarosi I, Bolon B, Tafuri A, Morony S,
Capparelli C, Li J, Elliott R, McCabe S, Wong T. Activated T
cells regulate bone loss and joint destruction in adjuvant ar-
thritis through osteoprotegerin ligand. Nature 1999; 402: 304-
309.
[25] Chabaud M, Fossiez F, Taupin JL, Miossec P. Enhancing effect
of IL-17 on IL-1-induced IL-6 and leukemia inhibitory factor
production by rheumatoid arthritis synoviocytes and its regu-
lation by Th2 cytokines. J Immunol 1998; 161: 409-414.
[26] Miossec P, Korn T, Kuchroo VK. Interleukin-17 and type 17
helper T cells. N Engl J Med 2009; 361: 888-898.
[27] Zheng SG. Regulatory T cells vs Th17: differentiation of Th17
versus Treg, are the mutually exclusive? Am J Clin Exp Im-
munol 2013; 2: 94-106.
[28] Behrens F, Himsel A, Rehart S, Stanczyk J, Beutel B, Zim-
mermann SY, Koehl U, Möller B, Gay S, Kaltwasser JP,
Pfeilschifter JM. Imbalance in distribution of functional au-
tologous regulatory T cells in rheumatoid arthritis. Ann Rheum
Dis 2007; 66: 1151-1156.
[29] van Amelsfort JM, Jacobs KM, Bijlsma JW, Lafeber FP,
Taams LS. CD4(+)CD25(+) regulatory T cells in rheumatoid
arthritis: differences in the presence, phenotype, and function
between peripheral blood and synovial fluid. Arthritis Rheum
2004; 50: 2775-2785.
[30] Liu MF, Wang CR, Fung LL, Lin LH, Tsai CN. The presence
of cytokine-suppressive CD4+ CD25+ T cells in the peripheral
blood and synovial fluid of patients with rheumatoid arthritis.
Scand J Immunol 2005; 62: 312-317.
[31] Möttönen M, Heikkinen J, Mustonen L, Isomäki P,
Luukkainen R, Lassila O. CD4+ CD25+ T cells with the phe-
notypic and functional characteristics of regulatory T cells are
enriched in the synovial fluid of patients with rheumatoid ar-
thritis. Clin Exp Immunol 2005; 140: 360-367.
[32] Cao D, Malmström V, Baecher‐Allan C, Hafler D, Klareskog
L, Trollmo C. Isolation and functional characterization of reg-
ulatory CD25brightCD4+T cells from the target organ of pa-
tients with rheumatoid arthritis. Eur J Immunol 2003; 33:
215-223.
[33] de Kleer IM, Wedderburn LR, Taams LS, Patel A, Varsani H,
Klein M, de Jager W, Pugayung G, Giannoni F, Rijkers G, Al-
bani S. CD4+CD25(bright) regulatory T cells actively regu-
late inflammation in the joints of patients with the remitting
DOI: http://dx.doi.org/10.18053/jctres.02.201603.005
 90 Farrugia and Baron | Journal of Clinical and Translational Research 2016; 2(3):84-90
form of juvenile idiopathic arthritis. J Immunol 2004; 172:
6435-6443.
[34] Ehrenstein MR, Evans JG, Singh A, Moore S, Warnes G, Is-
enberg DA, Mauri C. Compromised function of regulatory T
cells in rheumatoid arthritis and reversal by anti-TNF alpha
therapy. J Exp Med 2004; 200: 277-285.
[35] Lawson CA, Brown AK, Bejarano V, Douglas SH, Burgoyne
CH, Greenstein AS, Boylston AW, Emery P, Ponchel F, Isaacs
JD. Early rheumatoid arthritis is associated with a deficit in the
CD4 + CD25 high regulatory T cell population in peripheral
blood. Rheumatology 2006; 45: 1210-1217.
[36] Xiao H, Wang S, Miao R, Kan W. TRAIL is associated with
impaired regulation of CD4 + CD25- T cells by regulatory T
cells in patients with rheumatoid arthritis. J Clin Immunol
2011; 31: 1112-1119.
[37] Walter GJ, Fleskens V, Frederiksen KS, Rajasekhar M, Menon
B, Gerwien JG, Evans HG, Taams LS. Phenotypic, Functional,
and Gene Expression Profiling of Peripheral CD45RA+ and
CD45RO+ CD4+ CD25+ CD127low Treg Cells in Patients
with Chronic Rheumatoid Arthritis. Arthritis Rheumatol 2016;
68: 103-116.
[38] Sakaguchi S, Yamaguchi T, Nomura T, Ono M. Regulatory T
cells and immune tolerance. Cell 2008; 133: 775-787.
[39] Farrugia M, Baron B. Role of Regulatory T-cells in Oral Tol-
erance and Immunotherapy. Biochem Physiol 2016; 5: 2.
[40] van Amelsfort JM, van Roon JA, Noordegraaf M, Jacobs KM,
Bijlsma JW, Lafeber FP, Taams LS. Proinflammatory media-
tor-induced reversal of CD4+, CD25+ regulatory T cell-med-
iated suppression in rheumatoid arthritis. Arthritis Rheum
2007; 56: 732-742.
[41] Tetta C, Camussi G, Modena V, Di Vittorio C, Baglioni C.
Tumour necrosis factor in serum and synovial fluid of patients
with active and severe rheumatoid arthritis. Ann Rheum Dis
1990; 49: 665-667.
[42] Nadkarni S, Mauri C, Ehrenstein MR. Anti-TNF-alpha therapy
induces a distinct regulatory T cell population in patients with
rheumatoid arthritis via TGF-beta. J Exp Med 2007; 204:
33-39.
[43] Biton J, Semerano L, Delavallée L, Lemeiter D, Laborie M,
Grouard-Vogel G, Boissier MC, Bessis N. Interplay between
TNF and regulatory T cells in a TNF-driven murine model of
arthritis. J Immunol 2011; 186: 3899-3910.
[44] Chandrasekharan UM, Siemionow M, Unsal M, Yang L, Pop-
tic E, Bohn J, Ozer K, Zhou Z, Howe PH, Penn M, DiCorleto
PE. Tumor necrosis factor α (TNF-α) receptor-II is required
for TNF-α-induced leukocyte-endothelial interaction in vivo.
Blood 2007; 109: 1938-1944.
[45] Valencia X, Stephens G, Goldbach-Mansky R, Wilson M,
Shevach EM, Lipsky PE. TNF downmodulates the function of
human CD4 + CD25hi T-regulatory cells. Blood 2006; 108:
253-261.
[46] Nagar M, Jacob-Hirsch J, Vernitsky H, Berkun Y, Ben-Horin S,
Amariglio N, Bank I, Kloog Y, Rechavi G, Goldstein I. TNF
activates a NFkappaB-regulated cellular program in human
CD45RA-regulatory T cells that modulates their suppressive
Distributed under creative commons license 4.0
function. J Immunol 2010; 184: 3570-3581.
[47] Zanin-Zhorov A, Ding Y, Kumari S, Attur M, Hippen KL,
Brown M, Blazar BR, Abramson SB, Lafaille JJ, Dustin ML.
Protein kinase C-theta mediates negative feedback on regula-
tory T cell function. Science 2010; 328: 372-376.
[48] Zanin-Zhorov A, Lin J, Scher J, Kumari S, Blair D, Hippen
KL, Blazar BR, Abramson SB, Lafaille JJ, Dustin ML. Scaf-
fold protein Disc large homolog 1 is required for T-cell recep-
tor-induced activation of regulatory T-cell function. Proc Natl
Acad Sci U S A 2012; 109: 1625-1630.
[49] Cooles FAH, Isaacs JD and Anderson AE. Treg Cells in
Rheumatoid Arthritis: An Update. Curr Rheumatol Rep 2013;
15:1-9.
[50] Nie H, Zheng Y, Li R, Guo TB, He D, Fang L, Liu X, Xiao L,
Chen X, Wan B, Chin YE. Phosphorylation of FOXP3 controls
regulatory T cell function and is inhibited by TNF-α in rheu-
matoid arthritis. Nat Med 2013; 19, 322-328.
[51] Chen X, Bäumel M, Männel DN, Howard OZ, Oppenheim JJ.
Interaction of TNF with TNF receptor type 2 promotes expan-
sion and function of mouse CD4+CD25+ T regulatory cells. J
Immunol 2007; 179: 154-161.
[52] Zaragoza B, Chen X, Oppenheim JJ, Baeyens A, Gregoire S,
Chader D, Gorochov G, Miyara M, Salomon BL. Suppressive
activity of human regulatory T cells is maintained in the pres-
ence of TNF. Nat Med 2016; 22: 16-17.
[53] van Mierlo GJ, Scherer HU, Hameetman M, Morgan ME,
Flierman R, Huizinga TW, Toes RE. Cutting edge: TNFR-
shedding by CD4+CD25+ regulatory T cells inhibits the in-
duction of inflammatory mediators. J Immunol 2008; 180:
2747-2751.
[54] Black, R. A., C. T. Rauch, C. J. Kozlosky, J. J. Peschon, J. L.
Slack, M. F. Wolfson, B. J. Castner, K. L. Stocking, P. Reddy,
S. Srinivasan, Nelson N. A metalloproteinase disintegrin that
releases tumour-necrosis factor-alpha from cells. Nature 1997;
385: 729-733.
[55] MacEwan DJ. TNF receptor subtype signalling: differences
and cellular consequences. Cell Signal 2002; 14: 477-492
[56] Huang Z, Yang B, Shi Y, Cai B, Li Y, Feng W, Fu Y, Luo L,
Wang L. Anti-TNF-α therapy improves Treg and suppresses
Teff in patients with rheumatoid arthritis. Cell Immunol 2012;
279: 25-29.
[57] Nguyen DX, Ehrenstein MR. Anti-TNF drives regulatory T
cell expansion by paradoxically promoting membrane TNF-
TNF-RII binding in rheumatoid arthritis. J Exp Med 2016; 213:
1241-1253.
[58] Kodama S, Davis M, Faustman DL. The therapeutic potential
of tumor necrosis factor for autoimmune disease: a mechanis-
tically based hypothesis. Cell Mol Life Sci 2005; 62: 1850-
1862.
[59] Bloom BJ. Development of diabetes mellitus during etanercept
therapy in a child with systemic-onset juvenile rheumatoid ar-
thritis. Arthritis Rheum 2000; 43: 2606-2608.
[60] Tack CJ, Kleijwegt FS, Van Riel PL, Roep BO. Development
of type 1 diabetes in a patient treated with anti-TNF-alpha
therapy for active rheumatoid arthritis. Diabetologia 2009; 52:
1442-1444.
DOI: http://dx.doi.org/10.18053/jctres.02.201603.005